Oral zinc sulfate in the treatment of rosacea: a double-blind, placebo-controlled study

BACKGROUND: Rosacea is a skin problem not uncommonly encountered world-wide. There is a need for an effective and well-tolerated treatment for this disease. OBJECTIVE: To evaluate the efficacy and side-effects of zinc sulfate in rosacea in a randomized, controlled, double-blind trial. PATIENTS AND METHODS: Patients with rosacea who attended the outpatient Clinic of Dermatology and Venereology in Baghdad Teaching Hospital were recruited into this study between October 2002 and August 2004. A disease severity score was calculated for each patient. The patients were randomly allocated to receive either zinc sulfate 100 mg or identical placebo capsules three times per day. Zinc sulfate and placebo capsules were given in a double-blind manner. Following 3 months of starting the treatment, the patients crossed over, i.e. patients on placebo crossed over to zinc sulfate and those on zinc sulfate crossed over to placebo. RESULTS: Twenty-five patients with rosacea were included in this study: 16 (64%) females and nine (36%) males. Nineteen patients completed the study: 11 (58%) females and eight (42%) males. Patient age ranged from 21 to 64 years with a mean +/- SD of 48.2 +/- 9.3 years. Duration of the disease ranged from 1 to 14 years with a mean +/- SD of 4.4 +/- 3.2 years. In the group started on zinc sulfate, the score before therapy ranged from 5 to 11 with a mean +/- SD of 8 +/- 2.0. The mean started to decrease directly after the first month of therapy with zinc sulfate to a significantly lower level. After shifting to placebo treatment, the mean started to rise gradually in the fifth month but remained significantly lower than the levels before therapy. In the group started on placebo, the score before therapy ranged from 5 to 9 with a mean +/- SD of 7 +/- 1.3. The mean remained high in the first 3 months of therapy while the patients were on placebo. After shifting to zinc sulfate, the mean started to decrease after the fourth month to significantly low levels. No important side-effects were reported apart from mild gastric upset in three (12%) patients on zinc sulfate. CONCLUSION: Zinc sulfate was found to be a good option in the treatment of rosacea, as it was safe, effective and lacking important side-effects.     

Oxidative stress in patients with Behcet's disease: I correlation with severity and clinical parameters

The study was designed to investigate the possible correlation between some oxidative stress parameters in Behcet's disease and the clinical manifestations of the disease as well as the possible correlation with the disease severity. Seventy-six patients diagnosed according to the International Study Group criteria for Behcet's disease were included in the study. Sixty patients had mild-to-moderate disease and 16 patients had severe disease. Sixty matched control subjects were also included. After a full history and examination from each subject, 10 mL blood was drawn from each for analysis. Serum malondialdehyde, glutathione, ceruloplasmin, copper and zinc levels were determined. Patients with Behcet's disease showed increased levels of serum malondialdehyde and copper while glutathione and zinc levels were decreased. Comparison between these parameters in patients with mild-to-moderate disease with those with severe disease showed only that serum zinc levels were lower in severe Behcet's disease. Serum malondialdehyde levels were found to be significantly positively correlated with oral ulcer size, duration and frequency. Glutathione levels were found to be inversely correlated with the clinical manifestation index and all oral ulcer parameters. Zinc levels were found to be inversely correlated with the clinical manifestation index and pathergy test positivity grades. Copper levels were found to be positively correlated with oral ulcer number. Although the parameters of oxidative stress did not show correlation with disease severity, they were correlated with the disease manifestations. This points out the importance of oxidative stress in Behcet's disease.     

Oral zinc sulphate therapy in acne vulgaris: a double-blind trial

The effect of zinc sulphate and placebo was compared in a double-blind trial in 56 patients suffering from acne vulgaris. Serum vitamin A levels were studied in all, before and at the end of therapy, 29 patients received zinc sulphate 600 mg daily and 27 patients received placebo. Patients on placebo showed no improvement. After 12 weeks of treatment with zinc sulphate, 17 patients (58%) showed significant improvement. There was a statistically significant decrease in the number of papules, infiltrates and cysts. In zinc-treated cases there was statistically significant increase in serum vitamin A levels, while no change was found in the placebo group.     

Oral zinc sulphate in the treatment of recalcitrant viral warts: randomized placebo-controlled clinical trial

BACKGROUND: Viral warts are common dermatological diseases; although the rate of spontaneous recovery is high, it usually takes a long time, and some patients might not show this spontaneous healing. Zinc has an important effect on the immune system and it has been used as an immunomodulator to treat a variety of skin disorders. OBJECTIVE: To assess whether oral zinc was effective in treating viral warts of patients evaluated between May 1999 and April 2000. PATIENTS AND METHODS: This was a placebo-controlled clinical trial. Eighty patients with viral warts (common, plantar and plane) were all resistant to all forms of treatment. Each patient had > 15 warts. Forty patients were treated by oral zinc sulphate at a dose of 10 mg kg(-1) daily up to 600 mg day(-1) and followed-up for resolution of their warts and for any evidence of recurrence for 2-6 months. Another 40 patients were given a placebo oral treatment in the form of glucose, and followed-up for the same period. RESULTS: Only 23 patients of the first group (zinc treated) and 20 patients of the second group (placebo treated) completed the study. In all patients the serum level of zinc was low. In the zinc-treated group, the overall response was complete clearance of warts observed in 20 patients (86.9%) after 2 months of treatment. Fourteen patients (60.9%) showed complete disappearance of their warts after 1 month. Three patients (13.3%) failed to respond to the treatment after 2 months of therapy. The response to treatment was directly related to the increment in serum zinc level. No patient of the placebo-treated group showed any response. CONCLUSIONS: We conclude that zinc sulphate at a dose of 10 mg kg(-1) daily seems to be a highly efficacious therapeutic option for recalcitrant viral warts and proved to be safe with few adverse effects.     

Acne treatment with oral zinc and vitamin A: effects on the serum levels of zinc and retinol binding protein (RBP).

The serum levels of zinc, vitamin A and retinol binding protein (RBP) were studied in 75 acne patients before and during oral treatment with zinc, vitamin A or placebo. In the zinc-treated patients an increase in the mean serum zinc level was seen after 2 weeks, when also the first clinical improvement occurred. After 4 weeks the zinc level had increased by about 30% and no further significant increase was observed during 3 months of treatment. In 33 healthy subjects there was an increase of 14% after 4 weeks of zinc therapy. Vitamin A and placebo induced no significant changes in the serum zinc status. Prior to therapy the serum levels of vitamin A and RBP were lower in the acne patients than in the controls. Zinc + vitamin A treatment raised the serum RBP value to normal after 4 weeks. In patients given vitamin A alone, a probable increase in RBP was achieved. Zinc and placebo treatment did not change the serum level of RBP.     

Serum interleukin 18 and tumour necrosis factor-alpha levels are increased in Behcet's disease

Inflammation in Behcet's disease is thought to be mediated by cytokines derived from T-helper type 1 (Th1) lymphocytes. In this study, we tried to determine serum interleukin (IL)-18 and tumour necrosis factor (TNF)-alpha levels of patients with Behcet's disease. Twenty-seven patients with active Behcet's disease, and 20 healthy control subjects were included in this study. Differences between mean serum IL-18 and TNF-alpha level of patients with Behcet's disease were significantly increased when compared with the control group. A significant correlation was found between serum IL-18 and TNF-alpha levels of Behcet patients (rs = 0.627, P < 0.0001). IL-18 and TNF-alpha levels may be related to disease pathogenesis. Increased levels of IL-18 also support Th1 predominance in Behcet's disease.     

Topical Zinc Therapy for Acne Vulgaris

A double-blind study of 30 patients with mild to moderate acne vulgaris was conducted to evaluate the efficacy of a topically applied 2% zinc sulfate solution for acne therapy. Over a 12-week period, no difference was noted between placebo- and zinc-treated participants in regard to either the number or type of acne lesions. The irritancy due to topically applied zinc was significantly greater (p less than or equal to 0.05) than that due to the placebo. Zinc serum levels were not significantly elevated between the two regimens before, during, or after treatment. This study suggests that topical zinc therapy alone is not of significant benefit in the treatment of acne vulgaris.     

Topical Zinc Therapy for Acne Vulgaris

Abstract: A double-blind study of 30 patients with mild to moderate acne vulgaris was conducted to evaluate the efficacy of a topically applied 2% zinc sulfate solution for acne therapy. Over a 12-week period, no difference was noted between placebo- and zinc-treated participants in regard to either the number or type of acne lesions. The irritancy due to topically applied zinc was significantly greater (p 0.05) than that due to the placebo. Zinc serum levels were not significantly elevated between the two regimens before, during, or after treatment. This study suggests that topical zinc therapy alone is not of significant benefit in the treatment of acne vulgaris.     

Double-blind placebo-controlled study of long-term low-dose cyclosporin in the treatment of palmoplantar pustulosis

We previously showed in a double-blind, placebo-controlled study that cyclosporin at a dose of 2.5 mg/kg per day is an effective treatment for palmoplantar pustulosis (PPP). In the present randomized, double-blind, placebo-controlled multicentre study we treated 58 PPP patients with placebo or cyclosporin at an initial dose of 1 mg/kg per day. Disease activity was calculated from the number of fresh pustules. Treatment success was defined as the number of fresh pustules not exceeding 50% of the patients' own baseline pustule number. In cases of treatment success the dose of the test medication was not increased and the treatment was kept blinded for a maximum of 12 months. Blinding was broken only on treatment failure of the initial test medication dose. The mean blinded treatment time was 5.1 months for the patients receiving cyclosporin and 2.1 months for placebo (P < 0.01). Treatment was kept blinded for 12 months for seven patients in the cyclosporin and two in the placebo group (P < 0.05). Patients whose treatment code was broken continued in an open dose-finding part of the study with dose adjustments of cyclosporin every second month. In cases of treatment failure the dose of cyclosporin was increased in steps of 1 mg/kg per day; in cases of treatment success the cyclosporin dose was decreased by 1 mg/kg per day. The minimum and maximum doses were 1 and 4 mg/kg per day, respectively. The mean effective dose during the dose-finding part was between 1.2 and 1.7 mg/kg per day. Two patients did not respond to the highest dose of 4 mg/kg per day. In two patients serum creatinine levels increased by > 30% of their own baseline. The other main adverse events were hypertension (seven patients) and hypertrichosis (six patients). After stopping cyclosporin treatment the mean number of fresh pustules showed a maximum after 2 weeks with a continuous decline after that. Twelve months after completing the treatment the mean number of pustules was reduced to 20.0 compared with 63.6 at baseline (P < 0.001); 11 patients were free from pustules and two of these were totally cleared. We conclude that cyclosporin at 1–2 mg/kg per day is an effective and well tolerated treatment for PPP in most patients.     

Efficacy of itraconazole in the prophylactic treatment of pityriasis (tinea) versicolor.

BACKGROUND: Pityriasis (tinea) versicolor has a high tendency to recur after being treated successfully. Prophylactic treatment to reduce recurrence is needed. OBJECTIVE: To determine whether recurrence of pityriasis versicolor could be prevented by prophylactic itraconazole treatment. DESIGN: Open treatment followed by a randomized, double-blind, placebo-controlled phase. SETTING: Multinational outpatient centers. PATIENTS: A total of 239 consecutive patients were included; 238 started open treatment. A total of 209 patients started prophylactic treatment: 106 in the itraconazole group and 103 in the placebo group. INTERVENTIONS: Open treatment: itraconazole, 200 mg once daily for 7 days. Prophylactic treatment: itraconazole, 200 mg, or placebo twice daily 1 day per month for 6 consecutive months. MAIN OUTCOME MEASURES: Mycological cure rates at the end of open treatment and at the end of prophylactic treatment. RESULTS: Mycological cure at the end of open treatment was 92% (205/223). At the prophylactic treatment end point (6 months), mycological cure was 88% (90/102) in the itraconazole group and 57% (56/99) in the placebo group (P<.001). In open treatment, 11 patients were not able to be evaluated for efficacy. In prophylactic treatment, 4 patients in the itraconazole group and 4 in the placebo group were not able to be evaluated. Adverse events were reported during open treatment by 26 patients (11%) and during prophylactic treatment by 17 (16%) in the itraconazole group and 14 (14%) in the placebo group. No patients experienced any serious adverse events. CONCLUSIONS: Prophylactic itraconazole treatment is efficacious for pityriasis versicolor after 6 months, as is itraconazole in the treatment of pityriasis versicolor.     

Oral zinc sulfate treatment for viral warts: an open-label study

Viral warts, which are caused by the human papilloma virus, are a common problem in dermatology. Various modalities have been used to treat warts, but none are uniformly effective or directly antiviral. Recent studies show that oral zinc sulfate could be effective in the treatment of viral warts. Thirty-one patients with multiple, non-genital viral warts were recruited in this open-label clinical study. The patients were treated with oral zinc sulfate (10 mg/kg to a maximum dose of 600 mg/day) for 2 months and followed up with assessments for the resolution of their warts and for any evidence of recurrence after treatment. Among the 31 patients, 18 patients showed low serum zinc levels (58%). Of 26 patients who completed the study (84%), 13 (50%) showed complete resolution of their warts after 2 months of treatment. Complete responders remained free of lesions at 6-month follow-up. No serious side-effects were reported apart from nausea (16%), mild gastric pain (3%) and itching sensation (3%). Oral zinc sulfate was found to be a good option in the treatment of viral warts, as it was safe and effective without important side-effects.     

Oral zinc therapy of acne. Absorption and clinical effect.

In a double-blind controlled comparison that lasted eight weeks, tablets of zinc sulfate monohydrate, 411 mg total daily dosage, and a lactose placebo were administered orally to 22 male subjects with moderate acne. At the same time, levels of zinc were determined in serum and urine. There were no statistically significant differences in the lesion counts (papules, pustules, open comedones, and closed comedones) in the zinc-treated and lactose-treated cases, despite evidence in serum and urine of absorption of zinc. The data from this study indicate that oral zinc therapy has no early clinical effect on male patients with moderate acne.     

A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo

BACKGROUND: A previous uncontrolled, open trial of levamisole in patients with limited and slowly spreading vitiligo had shown that new lesions did not develop in 94% of patients after 2-4 months of treatment with the drug. OBJECTIVES: To assess the efficacy of levamisole in the treatment of slowly spreading, limited vitiligo. METHODS: In a randomized double-blind trial at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India, 60 patients with vitiligo involving < 2% of the body surface area and with slowly spreading disease (defined as one to five new lesions in the previous month or six to 15 new lesions in the previous 3 months) were randomly allocated to receive oral levamisole 150 mg or placebo on two consecutive days in a week. Children received oral levamisole 100 mg. All patients applied mometasone furoate 0.1% cream on the depigmented macules once daily. Patients were evaluated monthly for 6 months. The main outcome measure was the occurrence of new lesions, counted at each monthly visit. The secondary outcome measures comprised: (i) a dermatology-specific instrument, the Dermatology Life Quality Index or Children's Dermatology Life Quality Index questionnaires, which were completed by the patients at baseline and at every visit, and (ii) a general health questionnaire, the World Health Organization Quality of Life Brief Questionnaire, which was completed at baseline and at the end of the study. RESULTS: Forty-three patients completed 6 months of follow-up. The mean +/- SD number of new lesions that developed during the study period of 6 months was 1.9 +/- 2.0 (range 0-8) in the levamisole group and 1.8 +/- 2.0 (range 0-7) in the placebo group (P = 0.92). The proportion of patients who did not develop any further new lesions for the remainder of the study period was higher in the levamisole group at all the monthly evaluation points, although it was statistically significant (P = 0.05) only at the fourth month. Improvement in quality of life was similar in both groups. CONCLUSIONS: The study indicates that levamisole is not as effective in arresting disease progression as was observed in a previous open study. A study with a larger sample size is necessary to determine if levamisole is truly superior to placebo in this respect.     

Reactivity to trichophytin antigen in patients with onychomycosis: effect of terbinafine

BACKGROUND: Many patients with chronic dermatophytosis and onychomycosis have depressed cell-mediated immunity (CMI) to trichophytin. OBJECTIVE: The fungicidal properties of oral terbinafine provide a unique opportunity to explore whether elimination of antigen could restore CMI response in these patients. METHODS: A double-blind, placebo-controlled study evaluated the effect of terbinafine (250 mg/d for 12 weeks) on skin immunoreactivity to intradermal trichophytin antigen (TRIPA), mycologic status of the nail, and nail growth in patients with toenail onychomycosis. RESULTS: Skin reactivity, in an optimized, dose response challenge series to TRIPA was inversely related to disease chronicity. Mycologic/clinical response rates were 72%/84% for terbinafine and 0%/7% for placebo. Terbinafine increased the number of TRIPA reactors 2-fold and the mean TRIPA reaction area 4-fold; responses in placebo-treated patients were relatively unchanged. Of the 7 (of 25) patients receiving terbinafine who still had positive mycology 6 months after treatment, all were anergic to TRIPA at baseline and all but one remained so after treatment. CONCLUSION: Terbinafine treatment enhances and restores CMI to TRIPA in patients with Trichophyton rubrum onychomycosis and may thereby reduce susceptibility to reinfection. Terbinafine reversal of immunologic anergy may be an important model of microbial tolerance in chronic dermatophyte infections.     

Colchicine and benzathine penicillin in the treatment of Behçet disease: a case comparative study

Beh?et disease is a chronic relapsing disease characterized by multiple signs and symptoms such as recurrent orogenital ulceration, eye involvement, skin manifestations, and other systemic involvement. Multiple therapeutic modalities have been used to treat Beh?et disease. These agents act through different mechanisms and are associated with a variety of side effects. We performed a case-comparative study to evaluate efficacy of combined colchicine and benzathine penicillin in the treatment and prophylaxis of Beh?et disease. Sixty-six patients who fulfilled the international study group criteria for diagnosis of Beh?et disease were included. The patients were divided into three groups: group 1 (20 patients) received 1.2 Mu benzathine penicillin injection monthly; group 2 (21 patients) received two tablets of colchicine daily (each tablet contained 0.5 mg); and group 3 (25 patients) received both 1.2 Mu benzathine penicillin injection monthly and two tablets of colchicine daily. Each patient was followed up monthly for 5 months, 4 months on treatment and 1 additional month followup. The clinical manifestation index (CMI), the numerical sum of the clinical features, was calculated for each patient initially and then monthly. Pathergy test was performed for each patient monthly. The CMI was reduced by colchicine and benzathine penicillin treatment, and the reduction was highly significant. The reduction in the CMI remains satisfactory and good for 1 month after stopping the treatment. When each colchicine and benzathine Penicillin are used alone the index is also reduced significantly, but this reduction is much less than when both drugs are used together and there is also rapid and earlier relapse. Based on our findings, the combination of colchicine and benzathine penicillin appears to be of greater efficacy in the treatment of Beh?et disease than the use of either drug alone.     

Randomized, double-blind trial of 220 mg zinc sulfate twice daily in the treatment of rosacea

A 2006 article published in the International Journal of Dermatology reported that oral zinc sulfate 100 mg three times daily was associated with improvement in the severity of facial rosacea (Sharquie et al. 2006; 45: 857-861). The current study was undertaken to further assess the role of zinc in the management of rosacea. This was a randomized, double-blind trial of 220 mg of zinc sulfate twice daily for 90 days in patients with moderately severe facial rosacea at baseline. Subjects were recruited in the Upper Midwest USA between August 2006 and April 2008, and followed until July 2008. Forty-four subjects completed the trial (22 in each arm). Rosacea improved in both groups. There were no differences in magnitude of improvement based on rosacea severity scores between subjects receiving zinc sulfate and subjects receiving placebo (P=0.284). Serum zinc levels were higher in subjects receiving zinc (P<0.001). Oral zinc sulfate was not associated with greater improvement in rosacea severity compared with placebo in this study. Additional studies are needed to determine what role oral zinc may have in the management of rosacea.     

Double-blind, placebo-controlled study of oral calcitriol for the treatment of localized and systemic scleroderma

BACKGROUND: Various treatments including corticosteroids, nonsteroidal anti-inflammatory drugs, D-penicillamine, interferon gamma, cyclosporine, and cytostatic drugs have been used with limited success in both morphea and systemic sclerosis (SSc). OBJECTIVE: We investigated the effect of treatment with oral calcitriol in patients with localized or systemic scleroderma. METHODS: A randomized, double-blind, placebo-controlled study of 9 months' duration with a 6-month follow-up was performed at the Department of Dermatology. A total of 27 patients (7 patients with SSc and 20 with morphea) were selected on a minimal skin score of 3 for patients with morphea and 12 for those with SSc. Each patient received calcitriol (0.75 microg/day for 6 months plus 1.25 microg/day for 3 months) or placebo for 9 months. Efficacy parameters included skin score, measurement of serum markers of collagen synthesis and degradation and, additional for the patients with SSc, oral aperture measurements, lung function studies, and esophagus motility. RESULTS: The skin score in patients with morphea after 9 months' treatment showed no significant difference between the placebo and calcitriol groups (mean percentage reduction [SD] in skin score in the placebo group was -29.3 [57.9]; in the calcitriol group it was -19.4 [46.6]). The small group of patients with SSc was inadequate to allow us to draw any conclusions regarding efficacy. No significant change was found in the serum markers of collagen metabolism. CONCLUSION: In this study calcitriol was not more effective than placebo in patients with morphea. Because of the small group of patients with SSc treated, no conclusions regarding efficacy in SSc can be drawn.     

Intralesional zinc sulfate 2% vs intralesional vitamin D in plantar warts: A clinicodermoscopic study

Verrucae are benign proliferations seen in skin due to infection with papillomaviruses. There are different treatment strategies for warts but all of these treatments are painful, time consuming, expensive, and recurrence is common. To evaluate and compare the efficacy of intralesional 2% zinc sulfate solution vs vitamin D3 in the treatment of plantar warts, as well as reporting the side effects. This three‐armed randomized clinical trial included 105 patients presented with plantar warts divided into three groups, 35 patients per group. The first group received intralesional 2% zinc sulfate, the second group received intralesional 2% vitamin D3, and the third group received normal saline. Four sessions were done, one every 2 weeks. At the end of the study, patients showing complete response were more in zinc group (71.4%), vitamin D3 group (62.9%) compared to saline group (40%). Most of the patients in zinc group showed severe pain during injection (48.6%), most of the patients in vitamin D3 group showed mild pain (80%), while most of the patients in saline group showed no pain (57.1%). Both intralesional 2% zinc sulfate and vitamin D3 are effective in treatment of plantar warts, with zinc sulfate being more effective.     

Oral zinc sulphate therapy for acne vulgaris.

A double-blind controlled clinical trial was performed to evaluate the effect of oral zinc sulphate, 0.6 g daily, on acne vulgaris. Twenty patients received zinc sulphate tablets and 19 were given placebo tablets. Thirteen of the zinc group and 12 of the placebo group received their medication throughout a 12-week period, while the remaining patients were treated for 4 or 8 weeks. In all patients the numbers or papular and pustular acne lesions on the face and the back were significantly reduced, while larger infiltrates remained practically unaltered during the trial, which was performed from March through May 1975. No statistically significant difference in the improvement of the groups was demonstrable. Pretreatment serum zinc values, which were normal in all patients, rose significantly in the zinc group as well as in the control group, but the increase in the former was significantly higher. The negative therapeutical results might be attributable to the limited number of patients or related to the zinc dosage. Furthermore, the results might have been influenced by the unexplained rise in serum zinc values in the control group. A possible weak beneficial effect of zinc might also have been camouflaged by the seasonal variation in the severity of acne which was noted in this study.     

Serum zinc levels in patients with phlegmons as a marker of the severity of infection and the potential of zinc supplementation to reduce the risk of recurrence

We analyzed the serum zinc levels of 37 patients with 40 phlegmon lesions. The mean serum zinc level was 52.1 ± 16.4 μg/dL. The serum zinc level was negatively correlated with the C-reactive protein (CRP) level (r = ?0.66) and white blood cell (WBC) count (r = ?0.56). It was also positively correlated with the serum levels of albumin, hemoglobin, and hematocrit (r = 0.57, 0.50, and 0.50, respectively). Patients with serum zinc levels of <60 μg/dL had higher CRP levels and WBC counts (p < 0.005 and p < 0.05, respectively) and lower albumin, hemoglobin, and hematocrit levels (p < 0.001, p < 0.01, and p < 0.01, respectively), and were more likely to be hospitalized (p < 0.05) than those with serum zinc levels of ≥60 μg/dL. Patients with low serum zinc levels were given zinc tablets. Three of the seven patients who developed recurrent phlegmons did not develop any further lesions after taking zinc tablets for >10 months. Of the remaining patients, one only developed a minimal lesion, and another two experienced recurrence twice but did not have any further lesions for 10 and 15 months, respectively. These findings indicate that in patients with phlegmons the serum zinc level is a suitable marker of the severity of infection, and zinc supplementation reduces the risk of further recurrence in patients whose lesions relapse.